Judge rejects whistleblower lawsuit involving Epic billing software

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Dive Brief:

A federal judge in Florida tossed a whistleblower lawsuit alleging Epic’s software double-billed the government for anesthesia services, FierceHealthcare reported.

A former compliance review specialist with WakeMed Health filed the complaint in 2015, claiming Epic’s billing software submitted claims under both CMS’ current and past billing protocols for anesthesia services, causing “hundreds of millions of dollars” in fraudulent Medicare and Medicaid payments.

In dismissing the suit, U.S. District Judge James Moody Jr. said the whistleblower failed to make her case. “[Geraldine] Petrowski alleges only that Epic’s software could be used in such a way that would allow its hospital customers to generate bills that cause the Medicare program to double pay for certain aspects of professional anesthesia services,” Moody wrote. “This is woefully deficient because it is based on pure speculation.”

Dive Insight:

Under the False Claims Act, whistleblowers are allowed to bring suits on behalf of the government and are entitled to a portion of any recovered funds. However, the government declined to join Petrowski’s lawsuit, which was unsealed in November.

Fraud is a recurring problem in healthcare and occurs across different sectors. Payers and providers have faced large settlement amounts stemming from FCA allegations by whistleblowers. Among them is eClinicalWorks, which paid $155 million to settle allegations the EHR vendor misrepresented its software capabilities and paid $392,000 in kickbacks to customers who promoted its product.

In September, the U.S. Department of Justice charged two former executives with complicity in a Medicaid fraud scheme that allegedly directed pregnant women to Tenet hospitals in Georgia and South Carolina.

While whistleblowers provide a valuable conduit for exposing fraud, they must be able to back up their claims with evidence that demonstrates the accused intended to cheat the government.

In another recent case, a federal judge threw out a lawsuit that alleged UnitedHealth Group supplied false information to receive inflated Medicare Advantage payments. The judge said DOJ, which was a party to the suit, didn't show that the payer knew the submitted claims were false.